- Email: [email protected]
The South African prison system: medical services
J,>urnul of Ch
F,wm,rc
Mnhcme , 1994)
1. I,,5
IO7
d APS.‘Longman (iroup Lfd 1494 _
JOURNAL
OF
CLINICAL FORENSIC MEDICINE
/
PERSONAL
VIEW
The South African prison system: medical services S. A. Craven Ebenezer
Road, Wvnberg,
South Africu
The South African Prisons’ Department does not employ doctors. It is the responsibility of the relevant Province, acting as agent for the department of National Health and Population Development, to provide medical attention for both remand and sentenced prisoners. Legislation was recently passed enabling the Prisons’ Department to employ salaried doctors, but I believe it is desirable that the Department does not take advantage of this legislative change. This independence of the visiting medical practitioners is essential for the welfare of the prisoners, and is one of the few protective mechanisms against their abuse by the ‘system’. I work as a private general medical practitioner in the southern suburbs of Cape Town. I also do medicolegal work for the local police, and have 4 sessions per week at the local maximum security jail - Pollsmoor Prison. These sessions require me to do 80% of the general clinical work at the prison, including kitchen and other inspections. I am asked from time to time to comment on various aspects of prison medicine and procedures, and often submit unsolicited advice. Some of my suggestions are accepted; others are rejected. I cannot expect to win every battle! It is important to emphasise that for this work (at the prison and for the police) I am paid by the Province. The police and prison do not pay me, and do not have the power of hire and fire. I am not dependent on them for the major part of my income. I am therefore both independent, and am seen to be independent, of the ‘system’. Unfortunately, most prisoners are unaware of this independence, and regard the visiting doctor as being part of the ‘system’. I enjoy direct access to the Governor, and to the administrators in Pretoria. I did not seek approval of this paper by the prison authorities; I merely submitted it in advance for their information.
MEDICAL TREATMENT AND ASSESSMENT I have found during the course of my duties that there is very little easily available literature on prison medicine. There are useful books about prison medical management in the UK,’ and in Massachusetts, USA,’ and other publications which are older, but internationally orientated.3 To the best of my knowledge and belief, prison medicine does not feature in the curricula of medical schools. I am therefore practising with little idea of the problems which my colleagues face, and of how those problems are overcome. Similarly, I have found that many doctors practising outside prisons have little idea of what happens on the other side of the bars. There is however abundant literature on criminology and criminal sociology. Pollsmoor Maximum Security Prison is the major prison in the western Cape. It houses all the male medical and disciplinary problems referred from the satellite prisons in the large area between Springbok and George - about a 500 km radius. All awaiting trial and sentenced male prisoners from greater Cape Town come to Pollsmoor Maximum for sorting before being transferred elsewhere. At any one time there are about 2800 prisoners in residence with an average daily turnover of about 100. In common with many jails elsewhere in the world it suffers from overcrowding. To assist with the medical problems inevitable with these large numbers, there are fully qualified male and female nurses, many with psychiatric qualifications, and two clinical psychologists. It is they who are responsible for the smooth running of the medical services. They recognise the regular inmates, commence treatment of all the emergencies, issue all the treatments ordered, do the counselling and psychotherapy, and liaise with the outside hospitals and clinics. There is a hospital section into which are admitted those prisoners who require more attention than can be given in the general sections. All new arrivals are processed by the nursing staff. Many of those who claim to have no medical problem
S. A. Craven MA, BM, BCL, (Oxon), PhD (Cape Town), LRCP, MRCS. 301 Huis Vincent, Ebenezer Road. Wynberg 7800. South Africa. 105
106 Journal of Clinical Forensic Medicine
are subsequently found to have significant pathology, and are presented to the medical officer. Those who receive a sentence of 2 years or more are automatically presented to the doctor. It is surprising how many prisoners with plaster casts, recently sutured laparotomy scars and other signs of recent medical treatment say that they have ‘no medical complaint’. A determined effort is made to contact hospitals, clinics and private doctors with a view to ascertaining previous treatments given and further desired management. Despite this, in about 50% of cases the prisoner is unknown to the stated agency. In theory every prisoner is entitled to see the doctor. If every prisoner were to exercise that right, the system would collapse. The Pollsmoor equivalent of selfmedication for minor self-limiting complaints is the daily round by the section nurses. It is they who have the important task of issuing the Schedule 1 and 2 medications, and of deciding who shall be presented to the doctor. They do this job well, and prove that suitably trained nurses with medical support can relieve doctors of the management of much minor and self-limiting pathology. Regular visits are made by forensic and clinical psychiatrists. All other specialist medical services are currently provided by the local Provincial hospitals. Bearing in mind the cost of transporting and guarding these prisoners, I calculated that there would be a considerable saving of costs if visiting specialists were to see the prisoners at the jail. Plans have been approved for the provision of a proper hospital and specialist consulting rooms, which will enable many more prisoners to be treated on site by similarly independent specialists. No attempt is made to interfere with the medical management of the prisoners, be it inside or outside the jail. The fashionable topic of cost containment is not discussed, it being left to the individual doctor’s discretion. The only restriction is the widespread use of generic drugs - a standard practice throughout the Department of National Health and Population Development in South Africa.
MEDICAL DISORDERS
Having described the system, it is relevant to mention the types of medical problems which have to be treated. It is unfortunate that the prison keeps no statistic other than a daily head count; and what follows is therefore my clinical impression. The prison has very few civil debtors - they stay one night then pay! Illegal immigrants come from all over the world and, provided that they have no other charge
against them, are soon repatriated. This category of prisoner rarely appear to present medical problems. About 10% of the prisoners are bud in the sense that they are murderers, rapists and great train robbers, though a trend in the past year seems to show a marked increase in the numbers of those incarcerated for fraud. There are many prisoners who can be considered mad as they are mentally incapable of understanding the nature of their misdeeds. By far the most numerous are the sad. These are the socially inadequate, unskilled, illiterate, uneducated, unemployable, alcoholic, itinerant no-hopers who return repeatedly with short sentences for petty crimes. The commonest presenting medical problems are respiratory disease, trauma, gastrointestinal, dermatological, sexually transmitted disease and drug addiction. Respiratory problems are most common with chronic obstructive airways disease followed by viral infections, and inevitably pulmonary tuberculosis. My attempt to have the prison turned into a smoke-free zone failed because the authorities declined to withdraw the smoking privilege. However, they compromised by providing no-smoking cells for those prisoners who need or request them. All smoking prisoners are exhorted to desist, with a disappointing success rate. Traumatic injuries and alleged injuries are presented to the doctor and recorded for medico-legal purposes. Final reports are subsequently issued. Most injuries are sustained before admission to the jail. Many prisoners allege that they have been assaulted by the police and warders, although most have ‘no recent injury seen’. Of the other injuries, most are so trivial as to be of no legal and medical consequence. Although prison food is prepared in bulk and is somewhat monotonous, it is nutritionally adequate. Special diets are available for those in medical need. There is some evidence that prisoners do not always appreciate gourmet food. 4 Many prisoners gain weight; and deficiency diseases are unknown. However, many prisoners complain about the food, and have dyspeptic symptoms. This presents difficulties in deciding who should be sent to the local hospital for gastroscopy. The endoscopist is keeping a record of these prisoners, and comparing them with non-prisoners who undergo endoscopy. The preliminary results reveal that in 62% of prisoners pathology is detected, compared with 68% of non-prisoners. This suggests that the accuracy of the prison’s medical assessment of dyspepsia approximates to that in the outside community. Every batch of new arrivals introduces another infestation of ectoparasites into the prison. The recent installation of an industrial laundry resulted in an immediate reduction in the numbers of prisoners presenting with
The South African prison system: medical services
scabies, lice, fleas and acute glomerulonephritis. Infected wounds, veld sores and gravitational ulcers, acquired outside the prison, are commonplace. The first South African prisoner to be infected with Human Immune Deficiency Virus (HIV) died in 1987. Since then the numbers of known HIV infected inmates had increased to 184 in May 1992. If the present trend continues, it can be expected that by 1995 1 in 15 prisoners will be HIV infected. The Prisons’ department has introduced an AIDS containment strategy which is designed to identify those prisoners who may be infected. HIV tests are done on those considered to be at risk who include: 1) Those who have been in countries with known high HIV infection; 2) Those who have been charged with, or convicted of, sexual offences; 3) Homosexuals and those with multiple partners; 4) Those who request the test and 5) Those in whom it is otherwise clinically indicated. AIDS awareness programmes are run in the prison. Individual counselling is given to those who have the HIV test; and those who are found to be HIV positive are managed in accordance with the recommendations of the local HIV clinic. Sexually transmitted diseases are commonly acquired both inside and outside prison. Drug addiction fortunately is not a major problem inside Pollsmoor Prison. We receive alcoholics in transit to rehabilitation centres; and many prisoners admit to smoking dagga (cannabis) and to abusing mandrax and benzodiazepines. Heroin and cocaine addicts are conspicuous by their absence.
CONCLUSION
It is difficult to know if the prisoners are satisfied with the medical care they receive. Dissatisfied private patients change their doctors; this option is not available to prisoners. If it were, it would enable them to play off one doctor against another. Often, prisoners are malingerers; and others attempt to disrupt the system. They will never be satisfied. Others simulate illness in the hope that they will be sent to the local hospital, thereby facilitating escape, the making of telephone calls and the smuggling of contraband on their return to jail. Others are incapable of describing their symptoms and
107
of understanding the nature of their illness because of low IQs or inarticulacy. Overall, I believe that most prisoners are dissatisfied with the medical services because the doctor and nursing staff are usually unable to offer immediate and permanent relief of symptoms. As mentioned above, the commonest presenting complaint is respiratory; and the nonsmoking prisoner is a rarity. Such patients are advised to stop smoking - advice which is not well received and which is rarely taken. It does not matter on which side of the bars the patients happen to be - they have to help the doctor to help themselves. It is therefore not surprising that the most satisfied prisoners appear to be those with obvious pathology which can be quickly eliminated and which requires little or no effort on their part, e.g. inguinal herniae and hydrocoeles. The intelligent prisoners with genuine pathology appear to be satisfied with their management, if only because they are capable of understanding the nature of the illness. and of discussing it with the doctor. From time to time we receive letters from solicitors and human rights’ organisations alleging that their clients are not receiving medical attention. I investigate these complaints, and advise the Governor how to reply. In every case. so far, either the prisoner has not presented with a complaint, or he has received attention. South African prisons are not noted for the comfort that they offer to their inmates. Nevertheless, it is clear to me that for the vast majority of prisoners, conditions inside are better than they are outside. It is clear that most prisoners get better dental and medical care than they do outside at the time of writing. This is not to criticise the medical standards outside prison -- it is the prisoners who. for whatever reason before admission, do not bother to avail themselves of the available facilities. References I. Smith R. Prison Health Care. London: British Medical Association, 1984; p. 182 2. Prout C, Ross R N. Care and Punishment. The Dilemmas of Prison Medicine. Pittsburgh: University of Pittsburgh Press, 1988; p. 276 3. Medical Care of Prisoners and Detainees. In: Anon (Ed ) Ciba Foundation Symposium 16 (new series). Holland: Eke&r, 1973; p. 238 4. Burrell I. Riots on the menu at private prison that left out chips. Sunday Times 1993 Aug 29: p. 1.3
F,wm,rc
Mnhcme , 1994)
1. I,,5
IO7
d APS.‘Longman (iroup Lfd 1494 _
JOURNAL
OF
CLINICAL FORENSIC MEDICINE
/
PERSONAL
VIEW
The South African prison system: medical services S. A. Craven Ebenezer
Road, Wvnberg,
South Africu
The South African Prisons’ Department does not employ doctors. It is the responsibility of the relevant Province, acting as agent for the department of National Health and Population Development, to provide medical attention for both remand and sentenced prisoners. Legislation was recently passed enabling the Prisons’ Department to employ salaried doctors, but I believe it is desirable that the Department does not take advantage of this legislative change. This independence of the visiting medical practitioners is essential for the welfare of the prisoners, and is one of the few protective mechanisms against their abuse by the ‘system’. I work as a private general medical practitioner in the southern suburbs of Cape Town. I also do medicolegal work for the local police, and have 4 sessions per week at the local maximum security jail - Pollsmoor Prison. These sessions require me to do 80% of the general clinical work at the prison, including kitchen and other inspections. I am asked from time to time to comment on various aspects of prison medicine and procedures, and often submit unsolicited advice. Some of my suggestions are accepted; others are rejected. I cannot expect to win every battle! It is important to emphasise that for this work (at the prison and for the police) I am paid by the Province. The police and prison do not pay me, and do not have the power of hire and fire. I am not dependent on them for the major part of my income. I am therefore both independent, and am seen to be independent, of the ‘system’. Unfortunately, most prisoners are unaware of this independence, and regard the visiting doctor as being part of the ‘system’. I enjoy direct access to the Governor, and to the administrators in Pretoria. I did not seek approval of this paper by the prison authorities; I merely submitted it in advance for their information.
MEDICAL TREATMENT AND ASSESSMENT I have found during the course of my duties that there is very little easily available literature on prison medicine. There are useful books about prison medical management in the UK,’ and in Massachusetts, USA,’ and other publications which are older, but internationally orientated.3 To the best of my knowledge and belief, prison medicine does not feature in the curricula of medical schools. I am therefore practising with little idea of the problems which my colleagues face, and of how those problems are overcome. Similarly, I have found that many doctors practising outside prisons have little idea of what happens on the other side of the bars. There is however abundant literature on criminology and criminal sociology. Pollsmoor Maximum Security Prison is the major prison in the western Cape. It houses all the male medical and disciplinary problems referred from the satellite prisons in the large area between Springbok and George - about a 500 km radius. All awaiting trial and sentenced male prisoners from greater Cape Town come to Pollsmoor Maximum for sorting before being transferred elsewhere. At any one time there are about 2800 prisoners in residence with an average daily turnover of about 100. In common with many jails elsewhere in the world it suffers from overcrowding. To assist with the medical problems inevitable with these large numbers, there are fully qualified male and female nurses, many with psychiatric qualifications, and two clinical psychologists. It is they who are responsible for the smooth running of the medical services. They recognise the regular inmates, commence treatment of all the emergencies, issue all the treatments ordered, do the counselling and psychotherapy, and liaise with the outside hospitals and clinics. There is a hospital section into which are admitted those prisoners who require more attention than can be given in the general sections. All new arrivals are processed by the nursing staff. Many of those who claim to have no medical problem
S. A. Craven MA, BM, BCL, (Oxon), PhD (Cape Town), LRCP, MRCS. 301 Huis Vincent, Ebenezer Road. Wynberg 7800. South Africa. 105
106 Journal of Clinical Forensic Medicine
are subsequently found to have significant pathology, and are presented to the medical officer. Those who receive a sentence of 2 years or more are automatically presented to the doctor. It is surprising how many prisoners with plaster casts, recently sutured laparotomy scars and other signs of recent medical treatment say that they have ‘no medical complaint’. A determined effort is made to contact hospitals, clinics and private doctors with a view to ascertaining previous treatments given and further desired management. Despite this, in about 50% of cases the prisoner is unknown to the stated agency. In theory every prisoner is entitled to see the doctor. If every prisoner were to exercise that right, the system would collapse. The Pollsmoor equivalent of selfmedication for minor self-limiting complaints is the daily round by the section nurses. It is they who have the important task of issuing the Schedule 1 and 2 medications, and of deciding who shall be presented to the doctor. They do this job well, and prove that suitably trained nurses with medical support can relieve doctors of the management of much minor and self-limiting pathology. Regular visits are made by forensic and clinical psychiatrists. All other specialist medical services are currently provided by the local Provincial hospitals. Bearing in mind the cost of transporting and guarding these prisoners, I calculated that there would be a considerable saving of costs if visiting specialists were to see the prisoners at the jail. Plans have been approved for the provision of a proper hospital and specialist consulting rooms, which will enable many more prisoners to be treated on site by similarly independent specialists. No attempt is made to interfere with the medical management of the prisoners, be it inside or outside the jail. The fashionable topic of cost containment is not discussed, it being left to the individual doctor’s discretion. The only restriction is the widespread use of generic drugs - a standard practice throughout the Department of National Health and Population Development in South Africa.
MEDICAL DISORDERS
Having described the system, it is relevant to mention the types of medical problems which have to be treated. It is unfortunate that the prison keeps no statistic other than a daily head count; and what follows is therefore my clinical impression. The prison has very few civil debtors - they stay one night then pay! Illegal immigrants come from all over the world and, provided that they have no other charge
against them, are soon repatriated. This category of prisoner rarely appear to present medical problems. About 10% of the prisoners are bud in the sense that they are murderers, rapists and great train robbers, though a trend in the past year seems to show a marked increase in the numbers of those incarcerated for fraud. There are many prisoners who can be considered mad as they are mentally incapable of understanding the nature of their misdeeds. By far the most numerous are the sad. These are the socially inadequate, unskilled, illiterate, uneducated, unemployable, alcoholic, itinerant no-hopers who return repeatedly with short sentences for petty crimes. The commonest presenting medical problems are respiratory disease, trauma, gastrointestinal, dermatological, sexually transmitted disease and drug addiction. Respiratory problems are most common with chronic obstructive airways disease followed by viral infections, and inevitably pulmonary tuberculosis. My attempt to have the prison turned into a smoke-free zone failed because the authorities declined to withdraw the smoking privilege. However, they compromised by providing no-smoking cells for those prisoners who need or request them. All smoking prisoners are exhorted to desist, with a disappointing success rate. Traumatic injuries and alleged injuries are presented to the doctor and recorded for medico-legal purposes. Final reports are subsequently issued. Most injuries are sustained before admission to the jail. Many prisoners allege that they have been assaulted by the police and warders, although most have ‘no recent injury seen’. Of the other injuries, most are so trivial as to be of no legal and medical consequence. Although prison food is prepared in bulk and is somewhat monotonous, it is nutritionally adequate. Special diets are available for those in medical need. There is some evidence that prisoners do not always appreciate gourmet food. 4 Many prisoners gain weight; and deficiency diseases are unknown. However, many prisoners complain about the food, and have dyspeptic symptoms. This presents difficulties in deciding who should be sent to the local hospital for gastroscopy. The endoscopist is keeping a record of these prisoners, and comparing them with non-prisoners who undergo endoscopy. The preliminary results reveal that in 62% of prisoners pathology is detected, compared with 68% of non-prisoners. This suggests that the accuracy of the prison’s medical assessment of dyspepsia approximates to that in the outside community. Every batch of new arrivals introduces another infestation of ectoparasites into the prison. The recent installation of an industrial laundry resulted in an immediate reduction in the numbers of prisoners presenting with
The South African prison system: medical services
scabies, lice, fleas and acute glomerulonephritis. Infected wounds, veld sores and gravitational ulcers, acquired outside the prison, are commonplace. The first South African prisoner to be infected with Human Immune Deficiency Virus (HIV) died in 1987. Since then the numbers of known HIV infected inmates had increased to 184 in May 1992. If the present trend continues, it can be expected that by 1995 1 in 15 prisoners will be HIV infected. The Prisons’ department has introduced an AIDS containment strategy which is designed to identify those prisoners who may be infected. HIV tests are done on those considered to be at risk who include: 1) Those who have been in countries with known high HIV infection; 2) Those who have been charged with, or convicted of, sexual offences; 3) Homosexuals and those with multiple partners; 4) Those who request the test and 5) Those in whom it is otherwise clinically indicated. AIDS awareness programmes are run in the prison. Individual counselling is given to those who have the HIV test; and those who are found to be HIV positive are managed in accordance with the recommendations of the local HIV clinic. Sexually transmitted diseases are commonly acquired both inside and outside prison. Drug addiction fortunately is not a major problem inside Pollsmoor Prison. We receive alcoholics in transit to rehabilitation centres; and many prisoners admit to smoking dagga (cannabis) and to abusing mandrax and benzodiazepines. Heroin and cocaine addicts are conspicuous by their absence.
CONCLUSION
It is difficult to know if the prisoners are satisfied with the medical care they receive. Dissatisfied private patients change their doctors; this option is not available to prisoners. If it were, it would enable them to play off one doctor against another. Often, prisoners are malingerers; and others attempt to disrupt the system. They will never be satisfied. Others simulate illness in the hope that they will be sent to the local hospital, thereby facilitating escape, the making of telephone calls and the smuggling of contraband on their return to jail. Others are incapable of describing their symptoms and
107
of understanding the nature of their illness because of low IQs or inarticulacy. Overall, I believe that most prisoners are dissatisfied with the medical services because the doctor and nursing staff are usually unable to offer immediate and permanent relief of symptoms. As mentioned above, the commonest presenting complaint is respiratory; and the nonsmoking prisoner is a rarity. Such patients are advised to stop smoking - advice which is not well received and which is rarely taken. It does not matter on which side of the bars the patients happen to be - they have to help the doctor to help themselves. It is therefore not surprising that the most satisfied prisoners appear to be those with obvious pathology which can be quickly eliminated and which requires little or no effort on their part, e.g. inguinal herniae and hydrocoeles. The intelligent prisoners with genuine pathology appear to be satisfied with their management, if only because they are capable of understanding the nature of the illness. and of discussing it with the doctor. From time to time we receive letters from solicitors and human rights’ organisations alleging that their clients are not receiving medical attention. I investigate these complaints, and advise the Governor how to reply. In every case. so far, either the prisoner has not presented with a complaint, or he has received attention. South African prisons are not noted for the comfort that they offer to their inmates. Nevertheless, it is clear to me that for the vast majority of prisoners, conditions inside are better than they are outside. It is clear that most prisoners get better dental and medical care than they do outside at the time of writing. This is not to criticise the medical standards outside prison -- it is the prisoners who. for whatever reason before admission, do not bother to avail themselves of the available facilities. References I. Smith R. Prison Health Care. London: British Medical Association, 1984; p. 182 2. Prout C, Ross R N. Care and Punishment. The Dilemmas of Prison Medicine. Pittsburgh: University of Pittsburgh Press, 1988; p. 276 3. Medical Care of Prisoners and Detainees. In: Anon (Ed ) Ciba Foundation Symposium 16 (new series). Holland: Eke&r, 1973; p. 238 4. Burrell I. Riots on the menu at private prison that left out chips. Sunday Times 1993 Aug 29: p. 1.3